As
awareness of hereditary cancers grows, individuals who may be at risk on the
basis of a family history are pursuing risk determination and, as appropriate,
prophylactic medical or surgical intervention. Through news outlets and
health-related Internet Web sites, the public is increasingly aware of the
importance of genetic transmission and the possibilities of attenuating
heritable risk factors. One point emphasized is that heritable cancers tend to
arise in several close relatives and in multiple generations within the same
family.

Considering
that the expression of factitious disorders is limited only by an individual's
creativity and motivation, it is perhaps not surprising that alarming genetic
histories would be invoked by some individuals who seek the intangible benefits
of the "sick role."1 Unlike individuals who malinger for external
benefits such as money or abusable medications, patients with factitious disorder
deliberately produce or falsify illness to secure the attention, sympathy,
nurturance, and lenience of others. They may also manufacture illness to
manipulate and control others, to enhance their own self-esteem through
association with medical professionals, and to organize and preserve their
sense of identity.2

This case
report discusses a woman who chose to present herself as a member of a family
ravaged by a history of cancer. Like many individuals with factitious
disorders, she obtained unnecessary surgical intervention, this time in the
dramatic form of a prophylactic bilateral radical mastectomy. She meets
criteria for the diagnosis of factitious disorder in that she engaged in a
pattern of deliberately misleading health professionals about her background
while lacking any evident motivation beyond assuming the mantle of
"patienthood."

Searches of
MEDLINE (1966 to present), CancerLit (1975 to present), HealthSTAR (1975 to
present), and ISI Science Citation (1995 to present) computer databases failed
to uncover any previously published reports of prophylactic radical mastectomy
prompted by a false family history. However, one case of prophylactic
subcutaneous mastectomy based on a spurious family history has been reported.3

Case Report

Ms. A., a
40-year-old married medical paraprofessional, sought counseling at a genetics
clinic. She expounded on the successful battle she had waged against ovarian
cancer, first diagnosed a decade earlier. She went on to claim that her mother
had died of breast and ovarian cancer several years earlier and that three of
her sisters had breast cancer, one of whom had undergone a bilateral
mastectomy. Ms. A stated that her maternal grandmother, two maternal aunts, a
niece, and a cousin had also had bilateral mastectomies necessitated by cancer,
and that a paternal aunt was suffering from ovarian cancer. She also claimed to
have had five miscarriages. Relatives, a review of records, and ultimately the
patient herself confirmed that all of this information was false.

On the
basis of Ms. A.'s professed history, the examiner concluded that there was a
strong hereditary predisposition to breast and ovarian cancer and that Ms. A.'s
chance of carrying a corresponding genetic mutation (BRCA1 or BRCA2) approached
90 percent. Prophylactic mastectomy, about which the patient had inquired, was
endorsed as an option. She was cautioned that outside records would need to be
obtained to ensure that there were no misunderstandings about the various
cancer diagnoses, but apparently this task was not completed. Ms. A was advised
to undergo DNA testing but declined, invoking limited financial resources to
pay for the part not covered by insurance.

Subsequently,
Ms. A. was seen by a cancer specialist who, armed with the genetic clinic report,
agreed with her decision to proceed with prophylactic mastectomy. He noted that
several previous breast biopsies had revealed only fibrocystic disease and that
a radionuclide-enhanced mammogram was negative. Regardless, Ms. A. affirmed her
preference for mastectomy over anti-estrogen medication and close follow-up. A
bilateral radical mastectomy took place during the following month.

A
subsequent review of Ms. A.'s history disclosed a long history of misinforming
others that she had illnesses such as diabetes mellitus. Over time, these
assertions had been met with increasing disinterest and complacency. She had
also manufactured stories of personal crisis, ostensibly intended to mobilize
friends' support. However, she was not known to have undergone any unwarranted
surgery. There was little evidence for pursuit of external goals such as
obtaining financial compensation or evading criminal prosecution, and Ms. A.
had never engaged in litigation involving medical or other matters. Although
she had chronically solicited opioids for personal use from multiple
physicians, she did not request medication in the context of her concerns about
cancer. She had never been diagnosed with a mental disorder. Her family was
unaware until after the operation that it had taken place because she had
imparted false information. During a 4-hour "intervention" by her
family and friends and her priest, Ms. A. could not offer any consistent or
convincing explanation for her behavior; for instance, she claimed at one point
that she hoped the surgery would induce her husband to divorce her but could
not elaborate. At the end of the meeting, she agreed to psychiatric care but
changed her mind the next day.

Discussion

Factitious
breast ailments have been reported in the literature several times, but they
remain a relatively esoteric manifestation of factitious disorder. When it does
occur, factitious breast disease usually involves women who have deliberately
induced or aggravated dermatoses, infection, mastitis, ulceration, or bleeding
of the breast.4–8 One male patient mechanically constricted his nipple to cause
inflammation.9 In such cases, a perplexing disease pattern or the lack of a
consistent treatment response can suggest that medical deception is involved,5
as can an unusual history, histology, and localization.6 The presence of benign
breast disease can make the diagnostic process more complex, but false claims
of primary cancers in each breast, as described by Evans et al.3 in two cases,
are much more readily disproved.

When
factitious breast cancer itself has been observed, it often appears in
association with other false medical claims. For instance, Arteaga-Rodriguez et
al.10 described a woman who pretended to have paraplegia, tuberculosis, and
malignant tumors of the breast and other bodily sites, but each was
disconfirmed following a thorough work-up. Ultimately, she was diagnosed with
Munchausen syndrome, the most severe and chronic form of factitious disorder.11
As illustrated by Feldman and Escalona's patient,12 claims of having breast
cancer are sometimes supplemented by self-induced medical signs, such as severe
weight loss due to surreptitious dieting and alopecia from head-shaving rather
than purported chemotherapy.

Kerr et
al.13 encountered five women whose false family or personal histories led to
erroneous estimates of breast cancer risk. Of the five, several had sincerely
supplied information that was later shown to have been falsified by a family
member. The one patient who underwent mastectomy did have an authenticated
family history of breast cancer in numerous relatives, though she also reported
a personal cancer history that could not be confirmed. The type of mastectomy
performed was not described, and it is not clear whether any of the patients or
family members actually qualified for a diagnosis of factitious disorder as
opposed to malingering or a somatoform disorder. Regardless, factors that
enhanced detection in these cases, such as the patients' surprising lack of
knowledge about the particular treatments received by close relatives, were not
evident in the case of Ms. A. As a result of her compelling reports, and the
unlikelihood that a woman would seek the unnecessary removal of her breasts,
Ms. A.'s physicians took her reports at face value and did not carry out the
process of objective corroboration and confirmation. The false premise under
which surgery occurred—the report that there was a deeply troubling family
history of cancer—was not discovered until afterward. In contrast, Grenga and
Dowden14 discuss a patient who, like Ms. A., sought bilateral prophylactic
mastectomy because of a strongly positive family history of breast cancer;
however, the fabricated history was exposed prior to the operation, which was
then canceled. In a unique case report that led to concern and disappointment
among invited respondents, a patient who massively exaggerated her personal and
family medical histories was granted prophylactic bilateral simple mastectomy
even after the ruse was exposed.15 Although a psychiatrist had deemed her
competent to make this decision and physicians perceived that her anxiety about
cancer risk was genuine, one respondent pointed out that "informed
consent, a component of autonomy, is not upheld simply because the patient is
receiving the treatment she requests."

"Disease
forgery" can be achieved through one or more of several methods.
Individuals can provide false symptom reports, exaggerate symptoms, simulate
medical signs (e.g., seizures), falsify test results and other data, aggravate
spontaneous signs, or self-induce actual illness. In addition to its other
lessons, Ms. A.'s outcome illustrates that, even at the comparatively mild
level of inventing a family history, individuals may procure medical/surgical
intervention that proves irreversible. Medical and surgical caregivers should
be educated to the fact that there is peril in performing a drastic procedure
based solely on a patient's report of his/her family or personal history. In
addition, caregivers should view with concern a patient whose request for
mastectomy or other dramatic surgery appears premature or overeager and
liberally seek psychiatric consultation in such a case. Verification of the
history is invaluable and should be routine,16 though the acquisition of
releases of information and the records themselves can be laborious even when
the patient fully cooperates. Finally, psychiatrists can help educate other
physicians that unwarranted interventions, even when a patient has successfully
lied about his or her history, are potentially compensable through the legal
system.17